FEATURES
This column represents the opinions of the author and not necessarily those of the American Dental Association.
HEALTH POLICY PERSPECTIVES
The booming Medicaid market Marko Vujicic, PhD
D
entistry is in the midst of a major transition. One key driver of change is the Affordable Care Act (ACA), which has many provisions relevant to the dental care sector. A key provision of the ACA is Medicaid expansion, which has the potential to reshape the dental benefits landscape considerably. Let’s first look at trends in Medicaid before ACA. For more than a decade, public health insurance coverage for children was growing steadily with the expansion of Medicaid and the Children’s Health Insurance Program (CHIP). Because dental benefits for children are mandatory under Medicaid and CHIP, this trend altered the dental benefits landscape considerably. In 2000, 20% of US children had dental benefits through Medicaid and CHIP, 58% had dental benefits through private dental plans, and 22% had no dental benefits. By 2012, the percentage of US children with dental benefits through Medicaid and CHIP increased to 37%, whereas the percentage with private dental benefits decreased to 50%; the percentage with no form of dental benefits decreased and was cut almost in half to 13%.1 When it comes to children, Medicaid is no longer a low-income-only program, and income eligibility in most states is many times the federal poverty level. For adults, on the other hand, the pre-ACA trends have been different. Adult dental benefits are
136 JADA 146(2) http://jada.ada.org
not mandatory in Medicaid programs, and many states provide limited or no dental benefits.2 Medicaid eligibility did not expand for adults in the way it did for children during the past decade. There has been a steady decrease in private dental benefit coverage among US adults, and with no expansion of dental benefits coverage through Medicaid, the percentage of adults with no dental benefits has increased steadily. Looking forward, Medicaid expansion under the ACA will alter the dental benefits landscape significantly, particularly for adults. Medicaid expansion allows states to receive significant federal subsidies if they expand Medicaid eligibility for all low-income adults. Results of a recent analysis show that up to 8.3 million adults could gain dental benefits as a result of Medicaid expansion; in many states, Medicaid expansion is more a tsunami than a trickle. For example, approximately one-half of states that provide adult dental benefits and are expanding Medicaid could see at least a doubling and sometimes even a tripling of Medicaid enrollment. Even states not expanding Medicaid under the ACA still will see expansion in Medicaid rolls because of enhanced enrollment efforts, the so-called woodwork effect. In fact, of the 8.3 million adults expected to gain dental benefits beyond emergency care through Medicaid as a result of the ACA, 2.6 million of them are because of enhanced enrollment efforts.2 To put Medicaid expansion into context, let us compare it with the
February 2015
private dental benefits expansion. The ACA established health insurance marketplaces where consumers could purchase private health insurance and private dental benefits. Adult dental care is not considered essential under the ACA, and, as a result, adult dental benefits are not subject to the individual mandate. However, adult dental benefits still can be obtained voluntarily through the marketplaces, and, through April 2014, a total of 1.1 million adults enrolled in a private dental benefits plan across 36 states for which data are available. In these same 36 states, 4.2 million adults are expected to gain some level of dental benefits through Medicaid: a 4:1 difference.3 The figure4,5 shows similar data for the 19 states where the Medicaid program provides at least limited adult dental benefits and for which matched data are available on private dental benefits enrollment through health insurance marketplaces. Across these 19 states, a total of 3.3 million adults are expected to gain dental benefits through Medicaid compared with 425,000 who have enrolled in a private dental benefits plan via health insurance marketplaces: an 8:1 difference. The figure4,5 also shows that even in states that are not expanding Medicaid eligibility under the ACA, the dental benefits expansion via Medicaid (from the woodwork effect) is expected to be larger than the dental benefits expansion via the health insurance marketplaces. Clearly, the Medicaid market will grow faster than the private market even in most of the nonexpansion states.
THE ADULT DENTAL BENEFITS EXPANSION IN SELECT STATES
Public Dental Benefits via Medicaid
7,000 5,146
6,000 3,824
5,000 1,515
2,000 1,495
Montana
Nebraska
South Dakota
Wyoming
13,000 2,175 Alaska
28,000 49,483 Virginia
28,000 24,156
38,000 21,035 Louisiana
Indiana
38,000 37,501 North Carolina
141,000 18,746 Wisconsin
23,000 861 North Dakota
153,000
113,000 5,409 Iowa
8,194 Arkansas
32,358 New Jersey
52,628 Michigan
23,016
85,225 Pennsylvania
0
Ohio
100,000
45,580
200,000
6,227
300,000
New Mexico
236,000
400,000
States Not Expanding Medicaid Under the ACA
337,000
426,000
500,000
States Expanding Medicaid Under the ACA
496,000
600,000
590,000
700,000
632,000
800,000
Illinois
ESTIMATED NUMBER OF ADULTS GAINING DENTAL BENEFITS
FEATURES
Private Dental Benefits via Health Insurance Marketplaces
Figure. The adult dental benefits expansion in select states. ACA: Affordable Care Act. Sources: The Henry J. Kaiser Family Foundation4 and United States Department of Health & Human Services.5
The expanding Medicaid market also should be viewed in the context of the overall dental care economy. Dental care use has been decreasing steadily among adults for the past decade, a trend that has little to do with the recent economic downturn.6 The decrease in dental care use among adults is widespread. Adults with private dental benefits, as well as middle-income and highincome adults, are all visiting the dentist less.7 This decrease has led to a slowdown in dental care spending8 and has contributed significantly to stagnation in dentist earnings.9 The trends in dental care use among middle- and highincome adults are not expected to reverse in the near term, and dental care spending is projected to remain flat for several years.8 In an overall stagnant dental sector, Medicaid is a market segment that will grow substantially.
A final point of context is that low-income adults—the exact group Medicaid expansion targets—have experienced the most significant erosion in access to dental care over the past decade. They are also the most likely group to report avoiding or delaying needed dental care and to face cost barriers to dental care.10 They have experienced, by far, the most significant increase in the rate of emergency department visits for dental conditions this past decade.11 In contrast, low-income children have seen remarkable gains in access to dental care in recent years. Between 2000 and 2010, dental care use among children covered by Medicaid increased in all but 3 states. Dental care use among US children is at its highest level ever, and the largest gains over time have been among low-income children.7 Expanded coverage does not necessarily equal expanded access.
Several important policy issues need to be considered for the Medicaid expansion to translate to improved access to dental care. First, there is an enormous opportunity to apply the good practices gleaned from a decade of success in improving access to dental care for children covered by Medicaid to adults covered by Medicaid. There is strong evidence that a combination of patient education and outreach, streamlined administrative procedures, and enhanced provider incentives12,13 form a set of enabling conditions that promote success in Medicaid programs.14 But when it comes to financial incentives, for example, results from a recent analysis showed that Medicaid reimburses adult dental care services at much lower rates than it does child dental care services.15 Dental care services also are reimbursed much less generously
JADA 146(2) http://jada.ada.org
February 2015 137
FEATURES
than are primary medical care services in Medicaid, for which mandatory reimbursement increases were introduced as part of the ACA in 2013 and 2014.16 Second, there is emerging evidence that innovative dental care delivery models can play an important role in enhancing access to dental care for populations covered by Medicaid.17 Some of these models involve new types of dental care providers (for example, community dental health coordinators), whereas others do not. Third, new research suggests that, in general, the current dental care system has the capacity to absorb large influxes of adults with newly gained Medicaid dental benefits.18 Moreover, the supply of dentists will increase steadily in the coming years,19 and there is strong evidence that there is significant unused capacity in the dental care system.9 At the same time, Medicaid beneficiaries are much more likely to report difficulty finding a dentist than are those with private dental benefits.20 Taken together, the evidence suggests that sufficient capacity is available within the dental care system but that this capacity needs to be leveraged better to meet the expected growth in demand for dental care within the Medicaid market.
Dr. Vujicic is the chief economist and vice president, Health Policy Institute at the American Dental Association, 18th Floor, 211 E. Chicago Ave., Chicago, IL 60611, e-mail vujicicm@ ada.org. Address correspondence to Dr. Vujicic. Disclosure. Dr. Vujicic did not report any disclosures.
CONCLUSIONS
Looking forward, Medicaid expansion provides an enormous opportunity to address some of the critical issues concerning access to dental care for low-income adults in many states. To seize this opportunity, a serious effort is needed to implement evidence-based Medicaid reforms. A renewed focus on key enabling conditions can help translate the expanded Medicaid dental benefits coverage for adults to expanded access to dental care and, ultimately, improved oral health. n http://dx.doi.org/10.1016/j.adaj.2014.12.009 Copyright ª 2015 American Dental Association. All rights reserved.
138 JADA 146(2) http://jada.ada.org
1. Nasseh K, Vujicic M. Dental benefits expanded for children, young adults in 2012. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPIBrief_1014_5. ashx. Accessed December 10, 2014. 2. Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion. Health Policy Institute Research Brief. American Dental Association. February 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_0214_1.ashx. Accessed December 10, 2014. 3. Yarbrough C, Vujicic M, Nasseh K. Update: take-up of pediatric dental benefits in health insurance marketplaces still limited. Health Policy Institute Research Brief. American Dental Association. May 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPI%20Research %20Brief%20-%20Update%20Takeup%20of% 20Pediatric%20Dental%20Benefits.ashx. Accessed December 16, 2014. 4. The Henry J. Kaiser Family Foundation. Interactive: a state-by-state look at how the uninsured fare under the ACA. August 28, 2014. Available at: http://kff.org/interactive/ uninsured-gap/. Accessed December 8, 2014. 5. United States Department of Health & Human Services. Addendum to the health insurance marketplace summary enrollment report for the initial annual open enrollment period. May 1, 2014. Available at: http://aspe. hhs.gov/health/reports/2014/MarketPlace Enrollment/Apr2014/ib_2014Apr_enroll Addendum.pdf. Accessed December 8, 2014. 6. Vujicic M, Nasseh K. A decade in dental care utilization among adults and children (2001-2010). Health Serv Res. 2014;49(2):460-480. 7. Nasseh K, Vujicic M. Dental care utilization rate highest ever among children, continues to decline among working-age adults. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPIBrief_1014_4. ashx. Accessed December 10, 2014. 8. Nasseh K, Vujicic M. Dental expenditure expected to grow at a much lower rate in the coming years. Health Policy Institute Research Brief. American Dental Association. August 2013. Available at: http://www.ada.org/w/media/ADA/ Science%20and%20Research/HPI/Files/HPIBrief_ 0813_1.ashx. Accessed December 10, 2014. 9. Munson B, Vujicic M. Dentist earnings not recovering with economic growth. Health Policy Institute Research Brief. American Dental Association. December 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1214_1.ashx. Accessed December 10, 2014.
February 2015
10. Wall T, Nasseh K, Vujicic M. Fewer Americans forgoing dental care due to cost. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPIBrief_1014_6. ashx. Accessed December 10, 2014. 11. Wall T, Nasseh K. Dental-related emergency department visits on the increase in the United States. Health Policy Institute Research Brief. American Dental Association. May 2013. Available at: http://www.ada.org/sections/ professionalResources/pdfs/HPRCBrief_0513_1. pdf. Accessed December 10, 2014. 12. Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011;306(2):187-193. 13. Buchmueller TC, Orzol S, Shore-Sheppard LD. The effect of Medicaid payment rates on access to dental care among children. NBER Working Paper No. 19218. July 2013. Available at: http://www.nber.org/papers/w19218.pdf?new_ window¼1. Accessed December 10, 2014. 14. Nasseh K, Vujicic M. The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland and Texas [published online ahead of print December 7, 2014]. Health Serv Res. http:// dx.doi.org/10.1111/1475-6773.12265. 15. Nasseh K, Vujicic M, Yarbrough C. A ten-year, state-by-state, analysis of Medicaid feefor-service reimbursement rates for dental care services. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/ Science%20and%20Research/HPI/Files/ HPIBrief_1014_3.ashx. Accessed December 10, 2014. 16. Zuckerman S, Goin D. How much will Medicaid physician fees for primary care rise in 2013? Evidence from a 2012 survey of Medicaid physician fees. Urban Institute. December 2012. Available at: http://www.kff.org/medicaid/ upload/8398.pdf. Accessed September 5, 2014. 17. Robert Wood Johnson Foundation. New reports highlight oral health innovations, preventive care models: reviews spotlight prevention and access models at clinical and community settings. September 23, 2013. Available at: http://www.rwjf.org/en/about-rwjf/newsroom/ newsroom-content/2013/09/new-reportshighlight-oral-health-innovations--preventivecare-m.html. Accessed December 10, 2014. 18. Buchmueller TC, Miller S, Vujicic M. How do providers respond to public health insurance expansions? Evidence from adult Medicaid dental benefits. NBER Working Paper No. 20053. April 2014. Available at: http://www.nber.org/authors/ marko_vujicic. Accessed December 10, 2014. 19. Munson B, Vujicic M. Supply of dentists in the United States is likely to grow. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1014_1.ashx. Accessed December 10, 2014. 20. Yarbrough C, Nasseh K, Vujicic M. Why adults forgo dental care: evidence from a new national survey. Health Policy Institute Research Brief. American Dental Association. November 2014. Available at: http://www.ada.org/w/media/ ADA/Science%20and%20Research/HPI/Files/ HPIBrief_1114_1.ashx. Accessed December 10, 2014.
This column represents the opinions of the author and not necessarily those of the American Dental Association.
HEALTH POLICY PERSPECTIVES
The booming Medicaid market Marko Vujicic, PhD
D
entistry is in the midst of a major transition. One key driver of change is the Affordable Care Act (ACA), which has many provisions relevant to the dental care sector. A key provision of the ACA is Medicaid expansion, which has the potential to reshape the dental benefits landscape considerably. Let’s first look at trends in Medicaid before ACA. For more than a decade, public health insurance coverage for children was growing steadily with the expansion of Medicaid and the Children’s Health Insurance Program (CHIP). Because dental benefits for children are mandatory under Medicaid and CHIP, this trend altered the dental benefits landscape considerably. In 2000, 20% of US children had dental benefits through Medicaid and CHIP, 58% had dental benefits through private dental plans, and 22% had no dental benefits. By 2012, the percentage of US children with dental benefits through Medicaid and CHIP increased to 37%, whereas the percentage with private dental benefits decreased to 50%; the percentage with no form of dental benefits decreased and was cut almost in half to 13%.1 When it comes to children, Medicaid is no longer a low-income-only program, and income eligibility in most states is many times the federal poverty level. For adults, on the other hand, the pre-ACA trends have been different. Adult dental benefits are
136 JADA 146(2) http://jada.ada.org
not mandatory in Medicaid programs, and many states provide limited or no dental benefits.2 Medicaid eligibility did not expand for adults in the way it did for children during the past decade. There has been a steady decrease in private dental benefit coverage among US adults, and with no expansion of dental benefits coverage through Medicaid, the percentage of adults with no dental benefits has increased steadily. Looking forward, Medicaid expansion under the ACA will alter the dental benefits landscape significantly, particularly for adults. Medicaid expansion allows states to receive significant federal subsidies if they expand Medicaid eligibility for all low-income adults. Results of a recent analysis show that up to 8.3 million adults could gain dental benefits as a result of Medicaid expansion; in many states, Medicaid expansion is more a tsunami than a trickle. For example, approximately one-half of states that provide adult dental benefits and are expanding Medicaid could see at least a doubling and sometimes even a tripling of Medicaid enrollment. Even states not expanding Medicaid under the ACA still will see expansion in Medicaid rolls because of enhanced enrollment efforts, the so-called woodwork effect. In fact, of the 8.3 million adults expected to gain dental benefits beyond emergency care through Medicaid as a result of the ACA, 2.6 million of them are because of enhanced enrollment efforts.2 To put Medicaid expansion into context, let us compare it with the
February 2015
private dental benefits expansion. The ACA established health insurance marketplaces where consumers could purchase private health insurance and private dental benefits. Adult dental care is not considered essential under the ACA, and, as a result, adult dental benefits are not subject to the individual mandate. However, adult dental benefits still can be obtained voluntarily through the marketplaces, and, through April 2014, a total of 1.1 million adults enrolled in a private dental benefits plan across 36 states for which data are available. In these same 36 states, 4.2 million adults are expected to gain some level of dental benefits through Medicaid: a 4:1 difference.3 The figure4,5 shows similar data for the 19 states where the Medicaid program provides at least limited adult dental benefits and for which matched data are available on private dental benefits enrollment through health insurance marketplaces. Across these 19 states, a total of 3.3 million adults are expected to gain dental benefits through Medicaid compared with 425,000 who have enrolled in a private dental benefits plan via health insurance marketplaces: an 8:1 difference. The figure4,5 also shows that even in states that are not expanding Medicaid eligibility under the ACA, the dental benefits expansion via Medicaid (from the woodwork effect) is expected to be larger than the dental benefits expansion via the health insurance marketplaces. Clearly, the Medicaid market will grow faster than the private market even in most of the nonexpansion states.
THE ADULT DENTAL BENEFITS EXPANSION IN SELECT STATES
Public Dental Benefits via Medicaid
7,000 5,146
6,000 3,824
5,000 1,515
2,000 1,495
Montana
Nebraska
South Dakota
Wyoming
13,000 2,175 Alaska
28,000 49,483 Virginia
28,000 24,156
38,000 21,035 Louisiana
Indiana
38,000 37,501 North Carolina
141,000 18,746 Wisconsin
23,000 861 North Dakota
153,000
113,000 5,409 Iowa
8,194 Arkansas
32,358 New Jersey
52,628 Michigan
23,016
85,225 Pennsylvania
0
Ohio
100,000
45,580
200,000
6,227
300,000
New Mexico
236,000
400,000
States Not Expanding Medicaid Under the ACA
337,000
426,000
500,000
States Expanding Medicaid Under the ACA
496,000
600,000
590,000
700,000
632,000
800,000
Illinois
ESTIMATED NUMBER OF ADULTS GAINING DENTAL BENEFITS
FEATURES
Private Dental Benefits via Health Insurance Marketplaces
Figure. The adult dental benefits expansion in select states. ACA: Affordable Care Act. Sources: The Henry J. Kaiser Family Foundation4 and United States Department of Health & Human Services.5
The expanding Medicaid market also should be viewed in the context of the overall dental care economy. Dental care use has been decreasing steadily among adults for the past decade, a trend that has little to do with the recent economic downturn.6 The decrease in dental care use among adults is widespread. Adults with private dental benefits, as well as middle-income and highincome adults, are all visiting the dentist less.7 This decrease has led to a slowdown in dental care spending8 and has contributed significantly to stagnation in dentist earnings.9 The trends in dental care use among middle- and highincome adults are not expected to reverse in the near term, and dental care spending is projected to remain flat for several years.8 In an overall stagnant dental sector, Medicaid is a market segment that will grow substantially.
A final point of context is that low-income adults—the exact group Medicaid expansion targets—have experienced the most significant erosion in access to dental care over the past decade. They are also the most likely group to report avoiding or delaying needed dental care and to face cost barriers to dental care.10 They have experienced, by far, the most significant increase in the rate of emergency department visits for dental conditions this past decade.11 In contrast, low-income children have seen remarkable gains in access to dental care in recent years. Between 2000 and 2010, dental care use among children covered by Medicaid increased in all but 3 states. Dental care use among US children is at its highest level ever, and the largest gains over time have been among low-income children.7 Expanded coverage does not necessarily equal expanded access.
Several important policy issues need to be considered for the Medicaid expansion to translate to improved access to dental care. First, there is an enormous opportunity to apply the good practices gleaned from a decade of success in improving access to dental care for children covered by Medicaid to adults covered by Medicaid. There is strong evidence that a combination of patient education and outreach, streamlined administrative procedures, and enhanced provider incentives12,13 form a set of enabling conditions that promote success in Medicaid programs.14 But when it comes to financial incentives, for example, results from a recent analysis showed that Medicaid reimburses adult dental care services at much lower rates than it does child dental care services.15 Dental care services also are reimbursed much less generously
JADA 146(2) http://jada.ada.org
February 2015 137
FEATURES
than are primary medical care services in Medicaid, for which mandatory reimbursement increases were introduced as part of the ACA in 2013 and 2014.16 Second, there is emerging evidence that innovative dental care delivery models can play an important role in enhancing access to dental care for populations covered by Medicaid.17 Some of these models involve new types of dental care providers (for example, community dental health coordinators), whereas others do not. Third, new research suggests that, in general, the current dental care system has the capacity to absorb large influxes of adults with newly gained Medicaid dental benefits.18 Moreover, the supply of dentists will increase steadily in the coming years,19 and there is strong evidence that there is significant unused capacity in the dental care system.9 At the same time, Medicaid beneficiaries are much more likely to report difficulty finding a dentist than are those with private dental benefits.20 Taken together, the evidence suggests that sufficient capacity is available within the dental care system but that this capacity needs to be leveraged better to meet the expected growth in demand for dental care within the Medicaid market.
Dr. Vujicic is the chief economist and vice president, Health Policy Institute at the American Dental Association, 18th Floor, 211 E. Chicago Ave., Chicago, IL 60611, e-mail vujicicm@ ada.org. Address correspondence to Dr. Vujicic. Disclosure. Dr. Vujicic did not report any disclosures.
CONCLUSIONS
Looking forward, Medicaid expansion provides an enormous opportunity to address some of the critical issues concerning access to dental care for low-income adults in many states. To seize this opportunity, a serious effort is needed to implement evidence-based Medicaid reforms. A renewed focus on key enabling conditions can help translate the expanded Medicaid dental benefits coverage for adults to expanded access to dental care and, ultimately, improved oral health. n http://dx.doi.org/10.1016/j.adaj.2014.12.009 Copyright ª 2015 American Dental Association. All rights reserved.
138 JADA 146(2) http://jada.ada.org
1. Nasseh K, Vujicic M. Dental benefits expanded for children, young adults in 2012. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPIBrief_1014_5. ashx. Accessed December 10, 2014. 2. Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion. Health Policy Institute Research Brief. American Dental Association. February 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_0214_1.ashx. Accessed December 10, 2014. 3. Yarbrough C, Vujicic M, Nasseh K. Update: take-up of pediatric dental benefits in health insurance marketplaces still limited. Health Policy Institute Research Brief. American Dental Association. May 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPI%20Research %20Brief%20-%20Update%20Takeup%20of% 20Pediatric%20Dental%20Benefits.ashx. Accessed December 16, 2014. 4. The Henry J. Kaiser Family Foundation. Interactive: a state-by-state look at how the uninsured fare under the ACA. August 28, 2014. Available at: http://kff.org/interactive/ uninsured-gap/. Accessed December 8, 2014. 5. United States Department of Health & Human Services. Addendum to the health insurance marketplace summary enrollment report for the initial annual open enrollment period. May 1, 2014. Available at: http://aspe. hhs.gov/health/reports/2014/MarketPlace Enrollment/Apr2014/ib_2014Apr_enroll Addendum.pdf. Accessed December 8, 2014. 6. Vujicic M, Nasseh K. A decade in dental care utilization among adults and children (2001-2010). Health Serv Res. 2014;49(2):460-480. 7. Nasseh K, Vujicic M. Dental care utilization rate highest ever among children, continues to decline among working-age adults. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPIBrief_1014_4. ashx. Accessed December 10, 2014. 8. Nasseh K, Vujicic M. Dental expenditure expected to grow at a much lower rate in the coming years. Health Policy Institute Research Brief. American Dental Association. August 2013. Available at: http://www.ada.org/w/media/ADA/ Science%20and%20Research/HPI/Files/HPIBrief_ 0813_1.ashx. Accessed December 10, 2014. 9. Munson B, Vujicic M. Dentist earnings not recovering with economic growth. Health Policy Institute Research Brief. American Dental Association. December 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1214_1.ashx. Accessed December 10, 2014.
February 2015
10. Wall T, Nasseh K, Vujicic M. Fewer Americans forgoing dental care due to cost. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/Science% 20and%20Research/HPI/Files/HPIBrief_1014_6. ashx. Accessed December 10, 2014. 11. Wall T, Nasseh K. Dental-related emergency department visits on the increase in the United States. Health Policy Institute Research Brief. American Dental Association. May 2013. Available at: http://www.ada.org/sections/ professionalResources/pdfs/HPRCBrief_0513_1. pdf. Accessed December 10, 2014. 12. Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011;306(2):187-193. 13. Buchmueller TC, Orzol S, Shore-Sheppard LD. The effect of Medicaid payment rates on access to dental care among children. NBER Working Paper No. 19218. July 2013. Available at: http://www.nber.org/papers/w19218.pdf?new_ window¼1. Accessed December 10, 2014. 14. Nasseh K, Vujicic M. The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland and Texas [published online ahead of print December 7, 2014]. Health Serv Res. http:// dx.doi.org/10.1111/1475-6773.12265. 15. Nasseh K, Vujicic M, Yarbrough C. A ten-year, state-by-state, analysis of Medicaid feefor-service reimbursement rates for dental care services. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/w/media/ADA/ Science%20and%20Research/HPI/Files/ HPIBrief_1014_3.ashx. Accessed December 10, 2014. 16. Zuckerman S, Goin D. How much will Medicaid physician fees for primary care rise in 2013? Evidence from a 2012 survey of Medicaid physician fees. Urban Institute. December 2012. Available at: http://www.kff.org/medicaid/ upload/8398.pdf. Accessed September 5, 2014. 17. Robert Wood Johnson Foundation. New reports highlight oral health innovations, preventive care models: reviews spotlight prevention and access models at clinical and community settings. September 23, 2013. Available at: http://www.rwjf.org/en/about-rwjf/newsroom/ newsroom-content/2013/09/new-reportshighlight-oral-health-innovations--preventivecare-m.html. Accessed December 10, 2014. 18. Buchmueller TC, Miller S, Vujicic M. How do providers respond to public health insurance expansions? Evidence from adult Medicaid dental benefits. NBER Working Paper No. 20053. April 2014. Available at: http://www.nber.org/authors/ marko_vujicic. Accessed December 10, 2014. 19. Munson B, Vujicic M. Supply of dentists in the United States is likely to grow. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1014_1.ashx. Accessed December 10, 2014. 20. Yarbrough C, Nasseh K, Vujicic M. Why adults forgo dental care: evidence from a new national survey. Health Policy Institute Research Brief. American Dental Association. November 2014. Available at: http://www.ada.org/w/media/ ADA/Science%20and%20Research/HPI/Files/ HPIBrief_1114_1.ashx. Accessed December 10, 2014.
